Palliative Care and Symptom Burden in the Last Year of Life: A Population-Based Study of Patients with Gastrointestinal Cancer

Patterns of acute hospital and specialist palliative care use among people with non-curative upper gastrointestinal cancer

PURPOSE

Upper gastrointestinal (GI) cancers contribute to 16.7% of UK cancer deaths. These patients make high use of acute hospital services, but detail about palliative care use is lacking. We aimed to determine the patterns of use of acute hospital and hospital specialist palliative care services in patients with advanced non-curative upper GI cancer.

METHODS

We conducted a service evaluation of hospital use and palliative care for all patients with non-curative upper GI cancer seen in one large hospital, using routinely collected data (2019-2022). We report and characterise hospital admissions and palliative care within the study time period, using descriptive statistics, and multivariable Poisson regression to estimate the unadjusted and adjusted incidence rate ratio of hospital admissions.

RESULTS

The total with non-curative upper GI cancer was 960. 86.7% had at least one hospital admission, with 1239 admissions in total. Patients had a higher risk of admission to hospital if: aged ≤ 65 (IRR for 66-75 years 0.71, IRR 76-85 years 0.68; IRR > 85 years 0.53; p < 0.05), or lived in an area of lower socioeconomic status (IMD Deciles 1-5) (IRR 0.90; p < 0.05). Over the 4-year period, the rate of re-admission was higher in patients not referred to palliative care (rate 0.52 readmissions/patient versus rate 1.47 readmissions/patient).

CONCLUSION

People with advanced non-curative gastrointestinal cancer have frequent hospital admissions, especially if younger or from areas of lower socioeconomic status. There is clear association between specialist palliative care referral and reduced risk of hospitalisation. This evidence supports referral to specialist palliative care.

Associations between health-related quality of life and subsequent need for specialized palliative care and hospital utilization in patients with gastrointestinal cancer-a prospective single-center cohort study

BACKGROUND

We lack knowledge of which factors are associated with the risk of developing complex palliative care needs. The aim of this study was to investigate the associations between patient-reported health-related quality of life and subsequent referral to specialized palliative care (SPC) and hospital utilization.

METHODS

This was a prospective single-center cohort study. Data on patient-reported outcomes were collected through the European Organization of Research and Treatment of Cancer Questionnaire-Core-15-Palliative Care (EORTC QLQ-C15-PAL) at the time of diagnosis. Covariates and hospital utilization outcomes were collected from medical records. Adjusted logistic and Poisson regression were applied in the analyses. Participants were newly diagnosed with incurable gastrointestinal cancer and affiliated with a palliative care case management intervention established in a gastroenterology department.

RESULTS

Out of 397 patients with incurable gastrointestinal cancer, 170 were included in the study. Patients newly diagnosed with incurable gastrointestinal cancer experienced a substantial burden of symptoms. Pain was significantly associated with subsequent referral to SPC (OR 1.015; 95% CI 1.001-1.029). Patients with lower education levels (OR 0.210; 95% CI 0.056-0.778) and a Charlson Comorbidity Index score of 2 or more (OR 0.173; 95% CI 0.041-0.733) were less likely to be referred to SPC. Pain (IRR 1.011; 95% CI 1.005-1.018), constipation (IRR 1.009; 95% CI 1.004-1.015), and impaired overall quality of life (IRR 0.991; 95% CI 0.983-0.999) were significantly associated with increased risk of hospital admissions.

CONCLUSION

The study indicates a need for interventions in hospital departments to identify and manage the substantial symptom burden experienced by patients, provide palliative care, and ensure timely referral to SPC.

The symptom burden and the assessment of palliative symptoms in patients with metastatic upper gastrointestinal cancer: A qualitative interview study

OBJECTIVES

Patients with metastatic upper gastrointestinal (GI) cancer may experience a large physical symptom burden. However, less is known about existential, social, and psychological symptoms. To provide the patient with palliative care, quality-of-life questionnaires are used for structured needs assessment. These are sporadically implemented, and there seems to be uncertainty to the efficiency of current practice. The aim of study was to explore the experienced assessment-process and treatment of palliative symptoms, as well as the experienced symptom burden, in patients with metastatic upper GI cancer.

METHODS

Qualitative, semi-structured interviews were conducted in 10 patients with metastatic upper GI cancer. Data were analyzed using content analysis.

RESULTS

The patients did not expect treatment for all physical symptoms. Existential symptoms revolved around death and dying, social issues were mainly related to family, and psychological issues were based in the continuous dealing with serious illness. Existential, social, and psychological symptoms were mostly not considered part of the expected care when admitted to hospital. Patients had only vague recollections of their experiences with structured needs assessment, and the process had been inconsequential in the treatment of symptoms.

SIGNIFICANCE OF RESULTS

Patients with upper GI cancer experience symptoms related to all 4 areas of palliative care being physical, existential, social, and psychological, but these are differentiated in the way patients perceive their origins and treatability. Structured needs assessment was not routinely carried out, and in cases where this had been done, no follow-up was effectuated. This calls for increased focus and proper implementation for the process to be relevant in the treatment of palliative symptoms.

Care Delivery Interventions for Individuals with Cancer: A Literature Review and Focus on Gastrointestinal Malignancies

BACKGROUND

Gastrointestinal malignancies represent a particularly challenging condition, often requiring a multidisciplinary approach to management in order to meet the unique needs of these individuals and their caregivers.

PURPOSE

In this literature review, we sought to describe care delivery interventions that strive to improve the quality of life and care for patients with a focus on gastrointestinal malignancies.

CONCLUSION

We highlight patient-centered care delivery interventions, including patient-reported outcomes, hospital-at-home interventions, and other models of care for individuals with cancer. By demonstrating the relevance and utility of these different care models for patients with gastrointestinal malignancies, we hope to highlight the importance of developing and testing new interventions to address the unique needs of this population.

Qualitative evaluation of a palliative care case management intervention for patients with incurable gastrointestinal cancer (PalMaGiC) in a hospital department

PURPOSE

Generalist palliative care in hospital departments largely lacks an overall structure to fully manage the symptom burden and support needs of patients with incurable gastrointestinal cancer. Palliative care case management interventions show promising results in reducing healthcare use and enhancing quality of life. Less is known about these interventions and their potential to improve the quality of generalist palliative care in hospital departments. The aim of this study was to explore patients' experience of a palliative care case management intervention (PalMaGiC) to acquire knowledge about its advantages and disadvantages and, if needed, adjust the intervention.

METHODS

Qualitative semi-structured interviews with patients (n = 14) with incurable gastrointestinal cancers of the oesophagus, pancreas, colon, or rectum were conducted and analysed using content analysis. Participants in the study were affiliated with PalMaGiC, an intervention in a gastroenterology department based on symptom assessment, care planning, care coordination, and needs-based follow-up.

RESULTS

Participants perceived the intervention as filling a gap and as a secure lifeline in the healthcare system since it provided 24-h access, a designated specialist nurse, and a patient-healthcare alliance. Using a needs-based approach, PalMaGiC changed the participants' focus from disease to quality of life. Participants requested more open dialog within complementary and alternative medicine, greater focus on promoting hope and using need assessment questionnaires differently in assessing symptoms and problems.

CONCLUSION

The PalMaGiC intervention can potentially meet the needs of patients requiring palliative care in hospital departments, but further development of the content and personalised approach is needed.

Palliative Radiotherapy for Esophageal and Gastric Cancer: Population-Based Patterns of Utilization and Outcomes in Ontario, Canada

OBJECTIVE

Patients with incurable esophageal and gastric cancer may develop local symptoms for which palliative radiotherapy (PRT) may be considered. We sought to evaluate patterns in utilization and outcomes of patients receiving PRT for incurable esophageal and gastric cancer in Ontario, Canada using health administrative data.

METHODS

Linked health administrative databases were used to identify patients receiving PRT for incurable esophageal and gastric cancer. Primary outcomes were utilization and delivery of PRT, utilization of endoscopic dilation with or without stent insertion after completion of PRT and survival from 1) date of diagnosis and 2) start of PRT.

RESULTS

We identified 2500 patients who received PRT. Mean age was 70 ± 13 years and the majority (75%, n = 1873/2500) were male. Over half of the patients had a diagnosis of gastric cancer (58%, n = 1453/2500) and began PRT within 6 months of cancer diagnosis (85%, n = 2125/2500). Of the 2500 patients in the cohort, 2174 patients received EBRT with few receiving brachytherapy (n = 326) or EBRT and brachytherapy combined (n = 88). Over the study period, there was an increase in the number of patients receiving PRT (136 in 2007 to 290 in 2016), as well as in the use of advanced conformal radiotherapy techniques. Only 5% (115/2500) required dilation with or without stent insertion after completion of PRT. Median overall and cancer-specific survival of the cohort was 205 days and 209 days from date of diagnosis and 108 days and 110 days from start of PRT.

CONCLUSIONS

PRT is an important treatment for patients with incurable esophageal and gastric cancer who present with local symptoms. Utilization of PRT and advanced EBRT techniques increased over the study period. Few patients require endoscopic dilation with or without stent insertion after completion of PRT suggesting that PRT provides favorable symptom control.

Variation in hospital utilization of palliative interventions for patients with advanced gastrointestinal cancer near end of life

BACKGROUND

Patients with advanced gastrointestinal (GI) cancer often undergo noncurative interventions with palliative intent to relieve high symptom burden near end of life. Hospital-level variation in intervention utilization remains unclear.

METHODS

National cohort study of 142 304 patients with stage III or IV GI cancer within the National Cancer Database (2004-2014) who died within 1-year of diagnosis. Hospitals were stratified by palliative intervention utilization (surgery, chemotherapy, radiation, pain management). Multivariable, multinomial regression evaluated the association between patient/hospital factors and palliative intervention utilization.

RESULTS

Across 1322 hospitals, median hospital palliative intervention utilization was 12.0% [interquartile range: 0.0%-26.1%]. Utilization increased over time in all but lowest utilizing hospitals. Relative to lowest utilizing hospitals, factors associated with a lower likelihood of care at highest utilizing hospitals included: race (White [ref]; Black-Relative Risk Ratio [RRR] 0.81, 95% confidence interval [0.77-0.85]) and lower income (RRR 0.81 [0.78-0.84]). Factors associated with a higher likelihood included: lower education level (RRR 1.62 [1.55-1.69]) and hospital type (community program [ref]; comprehensive community-RRR 1.33 [1.26-1.41]; academic-RRR 1.88 [1.77-1.99]; integrated network-RRR 1.79 [1.66-1.93]).

CONCLUSION

Hospital variation in palliative intervention use is substantial and potentially associated with sociodemographic and hospital characteristics. Future work can examine how differences in hospital care processes translate to quantity/quality of life for cancer patients.

Views of inpatients on the prevention of venous thrombosis with ankle pump exercise: A cross-sectional survey

INTRODUCTION

This study investigated the current status of patients' knowledge and clinical compliance with ankle pump exercises in order to better enhance patient education and improve patient compliance with ankle pump exercises.

METHODS

A cross-sectional survey of the current status of ankle pump exercise awareness and compliance was conducted using a self-designed questionnaire. The questionnaire consisted of a general demographic information questionnaire, a questionnaire on patients' perceptions of ankle pump exercise and a compliance questionnaire.

RESULTS

A total of 2,203 patients from 53 clinical departments participated in this survey. 87.8% of patients considered ankle pump exercise important, 92.1% could grasp the knowledge of ankle pump exercise, 48.5% could self-monitor and exercise daily as instructed, 81.5% of health care workers would often supervise patients to complete ankle pump exercise, poor self-control (34.6%), lack of physical strength (21.1%) and perceived hassle (18.9%) were the top 3 factors contributing to patients' inability to complete the ankle pump exercise. Regression analysis showed that the factors influencing patients' compliance with the ankle pump exercise were literacy, economic level, number of comorbidities and caprini risk class (p < .05).

CONCLUSION

The patient's cognition of ankle pump exercise is good, but the compliance needs to be improved. It is suggested that the compliance of ankle pump exercise in hospitalized patients should be improved in the future to reduce the incidence of Venous thromboembolism.

The Use of Natural Language Processing to Assess Social Support in Patients With Advanced Cancer

BACKGROUND

Data examining associations among social support, survival, and healthcare utilization are lacking in patients with advanced cancer.

METHODS

We conducted a cross-sectional secondary analysis using data from a prospective longitudinal cohort study of 966 hospitalized patients with advanced cancer at Massachusetts General Hospital from 2014 through 2017. We used NLP to identify extent of patients' social support (limited versus adequate as defined by NLP-aided review of the Electronic Health Record (EHR)). Two independent coders achieved a Kappa of 0.90 (95% CI: 0.84-1.00) using NLP. Using multivariable regression models, we examined associations of social support with: 1) OS; 2) death or readmission within 90 days of hospital discharge; 3) time to readmission within 90 days; and 4) hospital length of stay (LOS).

RESULTS

Patients' median age was 65 (range: 21-92) years, and a plurality had gastrointestinal (GI) cancer (34.3%) followed by lung cancer (19.5%). 6.2% (60/966) of patients had limited social support. In multivariable analyses, limited social support was not significantly associated with OS (HR = 1.13, P = 0.390), death or readmission (OR = 1.18, P = 0.578), time to readmission (HR = 0.92, P = 0.698), or LOS (β = -0.22, P = 0.726). We identified a potential interaction suggesting cancer type (GI cancer versus other) may be an effect modifier of the relationship between social support and OS (interaction term P = 0.053). In separate unadjusted analyses, limited social support was associated with lower OS (HR = 2.10, P = 0.008) in patients with GI cancer but not other cancer types (HR = 1.00, P = 0.991).

CONCLUSION

We used NLP to assess the extent of social support in patients with advanced cancer. We did not identify significant associations of social support with OS or healthcare utilization but found cancer type may be an effect modifier of the relationship between social support and OS. These findings underscore the potential utility of NLP for evaluating social support in patients with advanced cancer.

In the weeds: a retrospective study of patient interest in and experience with cannabis at a cancer center

BACKGROUND

Cannabis products, including the cannabinoids CBD and THC, are rising in popularity and increasingly used for medical purposes. While there is some evidence that cannabinoids improve cancer-associated symptoms, understanding regarding appropriate use remains incomplete.

PURPOSE

To describe patient experiences with medical cannabis with focus on use contexts and patients' reported benefits and harms.

METHODS

A standardized intake form was implemented in a dedicated medical cannabis clinic at an NCI-designated cancer center; data from this form was abstracted for all initial visits from October 2019 to October 2020. We report descriptive statistics, chi-square analysis, and multivariate logistic regression.

RESULTS

Among 163 unique new patients, cannabis therapy was commonly sought for sleep, pain, anxiety, and appetite. Twenty-nine percent expressed interest for cancer treatment; 40% and 46% reported past use of CBD and THC, respectively, for medical purposes. Among past CBD users, the most commonly reported benefits were less pain (21%) or anxiety (17%) and improvement in sleep (15%); 92% reported no side effects. Among those with past THC use, reported benefits included improvement in appetite (40%), sleep (32%), nausea (28%), and pain (17%); side effects included feeling "high." Seeking cannabis for anti-neoplastic effects was associated with receipt of active cancer treatment in both univariate and multivariate analysis.

CONCLUSION

Cancer patients seek medical cannabis to address a wide variety of concerns despite insufficient evidence of benefits and harms. As more states move to legalize medical and recreational cannabis, cancer care providers must remain aware of emerging data and develop knowledge and skills to counsel their patients about its use.

End-of-life care of patients with esophageal or gastric cancer: decision making and the goal of care

BACKGROUND

Overall survival (OS) with advanced esophageal or gastric cancer is poor. To avoid overly aggressive treatments at the end-of-life and assure adequate end-of-life quality, the decision to focus on symptom-centered palliative care (PC) and terminate anticancer treatments, i.e., the PC decision, should be made in time.

MATERIAL AND METHODS

We reviewed the charts of patients (N = 160) with esophageal or gastric cancer treated at the Department of Oncology at Helsinki University Central Hospital in 2013 and deceased by December 2014. The use of acute services (Emergency department (ED) visits and hospitalizations) and places of death were compared according to the timing of the PC decision. Reasons for ED visits and hospitalizations were collected.

RESULTS

The median OS from diagnosis of advanced cancer was 6 months. Anti-cancer treatments were never started for 34% of the patients. The PC decision was made early (>30 days before death) for 54% of the patients and late (≤30 days before death) or not at all for 46%. Patients with late or no PC decision died more often in tertiary/secondary hospital (29 versus 7%, p = 0.001) and had more ED visits (49 versus 29%, p < 0.001) and hospitalizations (53 versus 28%, p = 0.001) in their last month, and visited the PC unit less often (18 versus 69%, p < 0.001), than the patients with early PC decision. The ED visits were most commonly related to cancer progression, and clinical deterioration (17%), fever (16%), and dysphagia (15%) were the most common symptoms.

CONCLUSION

The decision to focus on PC and terminate anticancer treatments, i.e., the PC decision, was made late or not at all in every other patient, leading to increased tertiary/secondary hospital service use and deaths at tertiary/secondary hospital. Early decision-making increased end-of-life care at specialized PC services or at home, implying better end-of-life care.

Use of Palliative Interventions at End of Life for Advanced Gastrointestinal Cancer

BACKGROUND

Despite the well-established benefits of palliative care, little is known about the use of palliative interventions among patients with advanced gastrointestinal (GI) cancer near the end of life (EOL).

METHODS

A national cohort study analyzed 142,304 patients with advanced GI cancers (stage 3 or 4) near EOL (death within 1 year of diagnosis) in the National Cancer Database (2004-2014) who received palliative interventions (defined as treatment to relieve symptoms: surgery, radiation, chemotherapy, and/or pain management). The study used multivariable hierarchical regression evaluate the association between the use of palliative interventions, temporal trends, and patient and hospital factors.

RESULTS

Overall, 16.5% of the patients were treated with a palliative intervention, and use increased over time (13.4% in 2004 vs 19.8% in 2014; trend test, p < 0.001). Palliative interventions were used most frequently for esophageal cancer (20.6%) and least frequently for gallbladder cancer (13.3%). Palliative interventions were associated with younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99), recent diagnosis year (OR, 1.05; 95% CI, 1.04-1.06), black race (white [ref]; OR, 1.07; 95% CI, 1.01-1.12), insurance status (no insurance [ref]; private: OR, 0.92; 95% CI ,0.95-0.99), hospital type (community cancer program [ref]; integrated network cancer programs: OR, 1.37; 95% CI ,1.07-1.75), and stage 4 disease (OR, 2.17; 95% CI, 2.07-2.27). Patients in southern and western regions were less likely to receive palliative intervention (Northeast [ref]; OR, 0.76; 95% CI, 0.62-0.94 and OR 0.46; 95% CI, 0.37-0.57, respectively).

CONCLUSION

Increased palliative intervention use over time suggests ongoing changes in how care is delivered to GI cancer patients toward EOL. However, sociodemographic and geographic variation suggests opportunities to address barriers to optimal EOL care.

Depression and anxiety during the year before death from cancer

OBJECTIVE

Previous studies of depression and anxiety during the year before death have reported different findings. We therefore aimed to study depression and anxiety in patients who had died from cancer and had previously attended cancer clinics.

METHODS

We analysed routine data on 4869 deceased patients who had completed the Hospital Anxiety and Depression Scale (HADS) as part of their routine cancer care. The HADS data were linked with demographic, cancer and mortality data from national registries. We used data from all HADS completed in the last year of life to investigate the relationships between mean depression (HADS-D) and anxiety (HADS-A) scores and the percentages of high scores (≥11 on each subscale) and time to death (Analysis 1). This analysis used multivariable linear regression with cubic splines and robust standard errors to allow for multiple HADS from the same patients. We also investigated within-patient changes in scores (Analysis 2) in a subset of patients who had completed more than one HADS.

RESULTS

In Analysis 1, modelled mean HADS-D scores increased by around 2.5 and the percentage of high HADS-D scores increased from 13% at six months before death to 30% at one month before death. Changes in HADS-A were smaller and occurred later. In Analysis 2, similar patterns were observed in individual patients' HADS scores.

CONCLUSION

Depression should be looked for and treated in patients with cancer and a prognosis of six months or less, in order to maximise the quality of patients' remaining life.

Variations in Care and Real World Outcomes in those with Rectal Cancer: A protocol for the Ontario Rectal Cancer Cohort (OntaReCC) (Preprint)

Background

Individuals with rectal cancer require a number of pretreatment investigations, often require multidisciplinary treatment, and require ongoing follow-ups after treatment is completed. Due to the complexity of treatments, large variations in practice patterns and outcomes have been identified. At present, few comprehensive, population-level data sets are available for assessing interventions and outcomes in this group.

Objective

Our study aims to create a comprehensive database of individuals with rectal cancer who have been treated in a single-payer, universal health care system. This database will provide an excellent resource that investigators can use to study variations in the delivery of care to and real-world outcomes of this population.

Methods

The Ontario Rectal Cancer Cohort database will include comprehensive details about the management and outcomes of individuals with rectal cancer who have been diagnosed in Ontario, Canada (population: 14.6 million), between 2010 and 2019. Linked administrative data sets will be used to construct this comprehensive database. Individual and care provider characteristics, investigations, treatments, follow-ups, and outcomes will be derived and linked. Surgical pathology details, including the stage of disease, histopathology characteristics, and the quality of surgical excision, will be included. Ethics approval for this study was obtained through the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board.

Results

Approximately 20,000 individuals who meet the inclusion criteria for this study have been identified. Data analysis is ongoing, with an expected completion date of March 2023. This study was funded through the Canadian Institute of Health Research Operating Grant.

Conclusions

The Ontario Rectal Cancer Cohort will include a comprehensive data set of individuals with rectal cancer who received care within a single-payer, universal health care system. This cohort will be used to determine factors associated with regional variability and adherence to recommended care, and it will allow for an assessment of a number of understudied areas within the delivery of rectal cancer treatment.

International Registered Report Identifier (IRRID)

RR1-10.2196/38874

Prevalence and severity of symptoms and signs in patients with advanced cancer in the last days of life: the East Asian collaborative cross-cultural study to elucidate the dying process (EASED)

PURPOSE

Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of specific symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer.

METHODS

In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients in the last 3 days of life according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer.

RESULTS

We analyzed 2131 patients from Japan, Korea, and Taiwan. The prevalence of most symptoms and signs were relatively stable from 1 week after admission to the last 3 days of life. According to cancer type, edema of the lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/respiratory secretion were the most severe symptoms.

CONCLUSION

We demonstrated the prevalence and severity of symptoms and signs associated with the impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the specific symptoms and signs at the very end of life.

Patients' preferred place of death: patients are willing to consider their preferences, but someone has to ask them

Background

end-of-life care is not always in line with end-of-life preferences, so patients do not always die at their preferred place of death (PPD). This study aims to identify factors associated with patients’ PPD and changes in PPD.

Methods

we prospectively collected data on PPD at four time points within 6 months from 230 acutely hospitalised older patients who were part of the control group in a stepped-wedge randomised controlled trial. Associations between patient characteristics and preferences were calculated using multivariable (multinomial) logistic regression analysis.

Results

the mean age of participants was 80.7 years. 47.8% of the patients had no PPD at hospital admission. Patients previously admitted to hospital preferred to die at home (home versus no preference: odds ratio [OR] 2.38, 95% confidence interval [CI] 1.15–4.92; home versus healthcare facility: OR 3.25, 95% CI 1.15–9.16). Patients with more chronic diseases preferred the healthcare facility as their PPD (healthcare facility versus no preference: OR 1.33, 95% CI 1.09–1.61; healthcare facility versus home: OR 1.21, 95% CI 1.00–1.47). 32 of 65 patients changed their preference during follow-up, and most of these had no PPD at hospital admission (home versus no preference: OR 0.005, 95% CI ≤0.001–0.095) and poorer self-rated well-being (OR 1.82, 95% CI 1.07–3.08).

Conclusions

almost half of the patients had no PPD at baseline. Previous hospital admission, having more chronic diseases and living alone are associated with having a PPD. Introducing PPD could make older people aware of PPD and facilitate optimal palliative care.

Self-Care Efficacy-Mediated Associations Between Healthcare Provider-Patient Communication and Psychological Distress Among Patients With Gastrointestinal Cancers

BACKGROUND

Both healthcare provider-patient communication and self-care efficacy affect psychological distress, which is prevalent among patients with gastrointestinal (GI) cancers. It is essential to explore the underlying mechanism among them to relieve psychological distress.

OBJECTIVE

The aim of this study was to examine whether self-care efficacy mediated the association between healthcare provider-patient communication and psychological distress among patients with GI cancers.

METHODS

A cross-sectional study was conducted between March 2018 and May 2019 in China. In total, 219 patients with GI cancers were recruited before discharge from chemotherapy. Healthcare provider-patient communication was assessed by the revised Physician-Patient Communication Scale; patient self-care efficacy was assessed by the Strategies Used by People to Promote Health; and psychological distress was assessed by the Distress Thermometer and the Hospital Anxiety and Depression Scale. Mediation analyses were conducted to examine the mediating effect of self-care efficacy on the association between healthcare provider-patient communication and psychological distress.

RESULTS

A total of 54.34% of patients experienced psychological distress. Patients reported a mean score of 89.93 (SD, 13.81) for healthcare provider-patient communication and 93.91 (SD, 23.39) for self-care efficacy. Self-care efficacy completely mediated the association between healthcare provider-patient communication and psychological distress, and communication outcome was the only domain that significantly influenced self-care efficacy.

CONCLUSION

Psychological distress is prevalent among patients with GI cancers. Healthcare provider-patient communication, especially communication outcome, promoted patients' self-care efficacy to reduce psychological distress.

IMPLICATIONS FOR PRACTICE

Healthcare providers should design interventions to improve communication outcomes and eventually increase self-care efficacy to relieve psychological distress among patients with GI cancers.

Best supportive care and prognosis: advanced gastroesophageal adenocarcinoma

OBJECTIVES

Real-world data are lacking on survival in patients with advanced gastroesophageal adenocarcinoma (GOA) treated with best supportive care (BSC) alone. This knowledge is vital to personalise cancer treatment and obtain informed consent. This study aimed to define and compare survival in patients with advanced GOA treated with and without palliative chemotherapy (CTx), and to explore the factors that impact prognosis.

METHODS

Patients in NHS Tayside, Scotland, diagnosed with advanced GOA (defined as non-resectable) over a 2-year period were identified retrospectively. Clinical data were obtained from electronic records. Kaplan-Meier and Cox regression analysis were performed to determine median overall survival (mOS) and investigate contributing factors.

RESULTS

127 eligible patients were identified. There was a significant difference in mOS between patients in the BSC and CTx groups (3.1 months vs 8.9 months, p=0.00089). This was maintained when those deemed not fit for CTx were removed. One-year survival was 16% versus 33%. Cox regression analysis in the BSC group identified stage (p<0.001) and Eastern Cooperative Oncology Group performance status (ECOG PS) (p=0.013) as having independent predictive value for survival. Age was not related to outcome. Palliative stents were inserted in 48 patients (37.8%).

CONCLUSIONS

To our knowledge, this is the largest reported study in Europe of outcomes in patients with advanced GOA treated with BSC only. The mOS with BSC is approximately 3 months. Cancer stage and ECOG PS have a role in prognostication at diagnosis. Our findings support the benefit of palliative chemotherapy in this population, and real-world survival corresponds to published trial data.

Real‑world challenge for clinicians treating advanced gastroesophageal adenocarcinoma (Review)

Gastroesophageal adenocarcinoma (GOA) is a disease of older people. Incidence is rising in the developed world and the majority of patients present with advanced disease. Based on clinical trial data, systemic chemotherapy in the advanced setting is associated with improvements in quality of life and survival. However, there is a recognised mismatch between trial populations and the patients encountered in clinical practice in terms of age, comorbidity and fitness. Appropriate patient selection is essential to safely deliver effective treatment. In this narrative review, we discuss the challenges faced by clinicians when assessing real‑world patients with advanced GOA for systemic therapy. We also highlight the importance of frailty screening and the current available evidence we can use to guide our management.

Artificial neural networks for simultaneously predicting the risk of multiple co-occurring symptoms among patients with cancer

Patients with cancer often exhibit multiple co-occurring symptoms which can impact the type of treatment received, recovery, and long-term health. We aim to simultaneously predict the risk of three symptoms: severe pain, moderate-severe depression, and poor well-being in order to flag patients who may benefit from pre-emptive early symptom management. This was a retrospective population-based cohort study of adults diagnosed with cancer between 2008 and 2015. We developed and tested an Artificial Neural Network (ANN) model to predict the risk of multiple co-occurring symptoms within 6 months after diagnosis. The ANN model derived from a training cohort was assessed on an independent test cohort for model performance based on sensitivity, specificity, accuracy, AUC, and calibration. The mutually exclusive training and test cohorts consisted of 35,606 and 10,498 patients, respectively. The area under the curve for the risk of experiencing severe pain, moderate-severe depression, and poor well-being were 71%, 73%, and 70%, respectively. Patient characteristics at highest risk of simultaneously experiencing these three symptoms included: those with lung cancer, late stage cancer, existing chronic conditions such as osteoarthritis, mood disorder, hypertension, diabetes, and coronary disease. Patients with over a 40% risk of severe pain also had over a 70% risk of depression, and over a 55% risk of poor well-being. Our ANN model was able to simultaneously predict the risk of pain, depression, and lack of well-being. Accurate prediction of future symptom burden can serve as an early indicator tool so that providers can implement timely interventions for symptom management, ultimately improving cancer care and quality of life.

First-Line Palliative Chemotherapy for Esophageal and Gastric Cancer: Practice Patterns and Outcomes in the General Population

PURPOSE

Clinical trials have shown that palliative chemotherapy (PC) improves survival in patients with incurable esophageal and gastric cancer; however, outcomes achieved in routine practice are unknown. We describe treatment patterns and outcomes among patients treated in the general population of Ontario, Canada.

METHODS

The Ontario Cancer Registry was used to identify patients with esophageal or gastric cancer from 2007 to 2016, and data were linked to other health administrative databases. Patients who received curative-intent surgery or radiotherapy were excluded. Factors associated with the receipt of PC were determined using logistic regression. First-line PC regimens were categorized, and trends over time were reported. Survival was determined using the Kaplan-Meier method.

RESULTS

The cohort included 9,848 patients; 22% (2,207 of 9,848) received PC. Patients receiving PC were younger (mean age, 63 v 74 years; P < .0001) and more likely male (71% v 65%; P < .0001). Thirty-seven percent of non-PC patients saw a medical oncologist in consultation. Over the study period, utilization of PC increased (from 11% in 2007 to 19% in 2016; P < .0001), whereas the proportion of patients receiving triplet regimens decreased (65% in 2007 to 56% in 2016; P = .04). In the PC group, the median overall and cancer-specific survival from treatment initiation was 7.2 months.

CONCLUSION

One fifth of patients with incurable esophageal and gastric cancer in the general population receive PC. Median survival of patients treated in routine practice is inferior to that in clinical trials. Only one third of patients not treated with PC had consultation with a medical oncologist. Further work is necessary to understand low utilization of PC and medical oncology consultation in this patient population.

Physical and psychological symptoms and signs in dying digestive tract cancer patients: the East Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED)

BACKGROUND

Well detection of the symptoms and signs of dying patients is essential for providing proper palliative care. Our goal is to evaluate the predominant symptoms and compare the changes in dying patients with digestive tract cancer in Japan, South Korea, and Taiwan.

METHODS

A total of 1057 cancer patients aged 18 years or older admitted in palliative care units with locally advanced or metastatic gastroesophageal, colorectal, and pancreaticobiliary cancer were enrolled from January 2017 to March 2019. The severity of physical and psychological symptoms and signs assessed by physicians and/or nurses upon admission, 1 week after admission, and within 3 days of death, was compared according to cancer type and country of origin.

RESULTS

Among the 338 gastroesophageal, 358 pancreaticobiliary, and 361 colorectal cancer patients, 894 (93.1%) died during the observation period. Fatigue was the most severe symptom in all cancer groups before dying. Dyspnea, fatigue, drowsiness, and ascites improved after hospitalization albeit they worsened prior to death. In particular, ascites was a marked symptom in patients with pancreaticobiliary cancer. Delirium and hallucination gradually worsened during the period leading to death. Differences in manifestations with respect to the country of origin were not significant.

CONCLUSION

We identified the most prevalent signs and symptoms in patients from East Asia who were dying from digestive tract cancers. Proper management, based on these prevalent signs and symptoms during the dying period, plays a vital role in providing adequate palliative care.

Symptom Evolution in Patients with Esophageal and Gastric Cancer Receiving Palliative Chemotherapy: A Population-Based Study

INTRODUCTION

Palliative chemotherapy (PC) is associated with a modest survival benefit in patients with incurable esophageal and gastric cancer; however, changes in symptom profile during treatment are not well described. Understanding the trajectory of symptoms during treatment may lead to improved care and facilitate shared decision making. In this study, we address this knowledge gap among all patients receiving PC in the Canadian province of Ontario.

METHODS

Patients diagnosed with incurable esophageal and gastric cancer who received PC from 2012 to 2017 were identified from the Ontario Cancer Registry. Patients with one or more recorded Edmonton Symptom Assessment System (ESAS) scores in the 12 months following cancer diagnosis were included. The ESAS includes scores from 0 to 10 in nine domains (anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and lack of well-being). Symptom severity is categorized as none-mild (≤ 3), moderate (4-6), or severe (7-10). We focused on potentially modifiable symptoms, i.e. nausea, pain, and anxiety/depression. Logistic regression was used to identify factors associated with moderate-severe ESAS scores in these domains. Among those patients with serial ESAS scores (at 8 ± 2 and 12 ± 2 weeks) receiving chemotherapy, we describe changes during treatment (decrease by ≥ 1 = improved; - 1 > 0 > 1 = unchanged; increase by ≥ 1 = deteriorated).

RESULTS

The cohort included 1900 patients who received PC, of whom 79% (1497/1900) had one or more recorded ESAS scores. In multivariate analysis, younger patients were more likely to have moderate-severe scores in nausea (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.23-2.90 [p < 0.01] in patients aged 41-50 years compared with patients aged ≥ 71 years) and pain (OR 1.88, 95% CI 1.36-2.60 [p < 0.01] in patients aged 51-60 years compared with patients aged ≥ 71 years). Compared with males, females were more likely to report moderate-severe scores in anxiety/depression (OR 1.58, 95% CI 1.21-2.08 [p < 0.01]). At 8 ± 2 weeks from PC initiation, symptom scores were unchanged in 19-42% of patients, improved in 30-51% of patients, and deteriorated in 17-35% of patients. The greatest change in symptom burden was observed for appetite (51% improvement) and anxiety/depression (35% deterioration). Similar trends were observed at 12 ± 2 weeks.

CONCLUSIONS

In this large, population-based study, we observed that younger patients were more likely to report moderate-severe symptoms in pain and nausea, and females were more likely to report moderate-severe symptoms in anxiety/depression. Anxiety/depression symptoms become increasingly problematic for a substantial proportion of patients receiving PC. Supportive care efforts to mitigate these symptoms in routine practice are needed.

Impact of palliative therapies in metastatic esophageal cancer patients not receiving chemotherapy

BACKGROUND

Palliative therapy has been associated with improved overall survival (OS) in several tumor types. Not all patients with metastatic esophageal cancer receive palliative chemotherapy, and the roles of other palliative therapies in these patients are limited.

AIM

To investigate the impact of other palliative therapies in patients with metastatic esophageal cancer not receiving chemotherapy.

METHODS

The National Cancer Database was used to identify patients between 2004-2015. Patients with M1 disease who declined chemotherapy and had known palliative therapy status [palliative therapies were defined as surgery, radiotherapy (RT), pain management, or any combination thereof] were included. Cases with unknown chemotherapy, RT, or nonprimary surgery status were excluded. Kaplan-Meier estimates of OS were calculated. Cox proportional hazards regression models were employed to examine factors influencing survival.

RESULTS

Among 140234 esophageal cancer cases, we identified 1493 patients who did not receive chemotherapy and had complete data. Median age was 70 years, most (66.3%) had a Charlson Comorbidity Index (CCI) of 0, and 37.1% were treated at an academic center. The majority (72.7%) did not receive other palliative therapies. On both univariate and multivariable analyses, there was no difference in OS between those receiving other palliative therapy (median 2.83 mo, 95%CI: 2.53-3.12) vs no palliative therapy (2.37 no, 95%CI: 2.2-2.56; multivariable P = 0.290). On univariate, but not multivariable analysis, treatment at an academic center was predictive of improved OS [Hazard ratio (HR) 0.90, 95%CI: 0.80-1.00; P = 0.047]. On multivariable analysis, female sex (HR 0.81, 95%CI: 0.71-0.92) and non-black, other race compared to white race (HR 0.72, 95%CI: 0.56-0.93) were associated with reduced mortality, while South geographic region relative to West region (HR 1.23, 95%CI: 1.04-1.46) and CCI of 1 relative to CCI of 0 (HR 1.17, 95%CI: 1.03-1.32) were associated with increased mortality. Higher histologic grade and T-stage were also associated with worse OS (P < 0.05).

CONCLUSION

Palliative therapies other than chemotherapy conferred a numerically higher, but not statistically significant difference in OS among patients with metastatic esophageal cancer not receiving chemotherapy. Quality of life metrics, inpatient status, and subgroup analyses are important for examining the role of palliative therapies other than chemotherapy in metastatic esophageal cancer and future studies are warranted.

Oncologic Services Through Project Access and Other Safety Net Care Coordination Programs

PURPOSE

Little is known about the provision of oncologic services by Project Access safety net care coordination programs.

MATERIALS AND METHODS

Information on safety net care coordination program locations, health services, and patient eligibility was obtained via program Web sites and calls. For programs not offering oncologic care, program directors were interviewed to identify oncologic care barriers.

RESULTS

Web sites of 29 safety net care coordination programs in 22 states were identified; 62% (n = 18) offered oncologic services. Programs were in 65% (n = 11) of states that did not expand Medicaid. Of those offering oncologic services, 83% (n = 15) offered free chemotherapy, and 93% (n = 27) of all programs offered oncologic imaging. Program director interviews revealed costs, longitudinal care, and multiple-physician buy-in as barriers limiting oncologic care.

CONCLUSION

Third-party care coordination centers provide a novel and potentially unrecognized approach to increasing oncology service access. Further research should identify strategies to overcome the relative lack of oncologic care offerings.

Embedded palliative care for patients with metastatic colorectal cancer: a mixed-methods pilot study

PURPOSE

Palliative care is recommended for patients with metastatic cancer, but there has been limited research about embedded palliative care for specific patient populations. We describe the impact of a pilot program that provided routine, early, integrated palliative care to patients with metastatic colorectal cancer.

METHODS

Mixed methods pre-post intervention cohort study at an academic cancer center. Thirty control then 30 intervention patients with metastatic colorectal cancer were surveyed at baseline and 1, 3, 6, 9, and 12 months thereafter about symptoms, quality-of-life, and likelihood of cure. We compared survey responses, trends over time, rates of advance care planning, and healthcare utilization between groups. Patients, family caregivers, and clinicians were interviewed.

RESULTS

Patients in the intervention group were followed for an average of 6.5 months and had an average of 3.5 palliative care visits. At baseline, symptoms were mild (average 1.85/10) and 78.2% of patients reported good/excellent quality-of-life. Half (50.9%) believed they were likely to be cured of cancer. Over time, symptoms and quality-of-life metrics remained similar between groups, however intervention patients were more realistic about their likelihood of cure (p = 0.008). Intervention patients were more likely to have a surrogate documented (83.3% vs. 26.7%, p < 0.0001), an advance directive completed (63.3% vs. 13.3%, p < 0.0001), and non-full code status (43.3% vs. 16.7%, p < 0.03). All patients and family caregivers would recommend the program to others with cancer.

CONCLUSIONS

We describe the impact of an embedded palliative care program for patients with metastatic colorectal cancer, which improved prognostic awareness and rates of advance care planning.

Older Adult Cancer Patients Under Palliative Care With a Prognosis of 30 Days or More: Clinical and Nutritional Changes

Objective: The aim of this study was to characterize nutritional status, body composition, oxidative stress, and inflammatory activity and to determine the possible associations between nutritional status and clinical variables in advanced cancer patients.Method: This was a cross-sectional study of 46 elderly cancer patients under palliative care with a prognosis of 30 days or more. Nutritional status, food intake, anthropometry, body composition (deuterium oxide method), metabolic profile, inflammation damage (C-reactive protein), oxidative damage (8-hydroxy-2'-deoxyguanosine), and symptom intensity were evaluated.Results: Among elderly cancer patients, 36.9% were malnourished or at risk of malnutrition. Systemic inflammation was detected, with a correlation between worse nutritional status and higher C-reactive protein levels (p < 0.01, r= -0.57), while lower lean mass (p < 0.01, r = 0.62) and higher fat mass percentages (p < 0.01, r = 0.62) correlated with higher levels of 8-hydroxy-2'-deoxyguanosine. Furthermore, daily energy (n = 25; 57.4%) and protein intake (n = 24; 52.2%) were lower than recommended in more than half the patients. The most prevalent symptoms were anxiety, impairment of well-being, drowsiness, tiredness, and lack of appetite.Conclusions: Despite preserved functionality, patients already had clinical and laboratory changes that, together with inadequate food intake, risk of malnutrition, systemic inflammation, and the presence of uncontrolled symptoms, alerted to the importance of an early and comprehensive palliative approach.

Association Between the Timing of Goals-of-Care Discussion and Hospitalization Outcomes in Patients With Metastatic Cancer

BACKGROUND

Patients with cancer often require acute hospitalizations, many of which are unplanned. These hospitalizations have been shown to increase in frequency near the end of life. The American College of Physicians recommends that goals-of-care (GOC) discussions be initiated early for metastatic cancers. We hypothesized that discussing GOC during hospitalization could help reduce readmissions. Our aim was to examine the association between the timing of GOC discussion, length of hospital stay, and the time to readmission.

METHODS

We conducted a retrospective review of medical records of patients with stage IV cancers hospitalized between August 2017 and July 2018. We recorded timing of GOC discussion, use of palliative care services, and hospital readmissions within 90 days. χ² tests were used to identify independent associations with GOC discussion, and logistic regression was used to examine association with readmission within 90 days.

RESULTS

Of all study patients (N = 241), 40.6% were female, 46% (n = 112) had a GOC discussion, and 34% (n = 82) had a palliative care consultation. Having a palliative care consult and being admitted to critical care were independently associated with having a GOC discussion. Early timing of GOC discussion was inversely associated with admission to critical care units (P < .05). Thirty-eight percent (n = 92) had unplanned hospital readmission within 90 days. Having a GOC discussion was independently associated with a reduction in the odds of an unplanned hospital readmission within 90 days by 79% (odds ratio = 0.21, 95% confidence interval: 0.12-0.37).

CONCLUSION

Among hospitalized patients with stage IV cancer, performing an early GOC discussion has an important association with lower hospital readmission rates and increased rates of goal-congruent patient care.

Hospice utilization among Medicare beneficiaries dying from pancreatic cancer

BACKGROUND

Use of hospice services among patients with pancreatic cancer following pancreatic resection remains unknown.

METHODS

Patients with pancreatic cancer who underwent resection were identified in the Medicare Standard Analytic Files. Outcomes included overall hospice use, early hospice enrollment (≥4 weeks before death), late hospice enrollment (initiation within 3 days of death), and Medicare expenditures.

RESULTS

Among the 4369 deceased individuals, three-fourths of patients (n = 3252, 74.4%) used hospice at the time of death. Patients who did not use hospice were more likely to be male, have a complication on index admission and receive life sustaining treatments on subsequent admissions (P < .05). Only one-third (32.2%) of patients initiated hospice services early. Medicare expenditure during the last month of life was $10 000 lower among patients who initialized hospice services at least 1 month before death versus within 3 days of death (late: $10 581 [$5454-$17 200], early: $221 [$46-$733]; P < .001) CONCLUSION: While three-fourths of patients utilized hospice services after pancreatic resection, only one-third of patients initiated hospice services at least one-month before death. Late hospice use was associated with higher Medicare expenditures during the last month of life. Further research is needed to understand barriers to early hospice utilization.